Dec 3, 2020 4 min read

Greg Spencer’s life changed once he was diagnosed with chronic obstructive pulmonary disease (COPD).

“I lost all of my strength and struggled to perform routine tasks,” Spencer said. “There were six months when I actually couldn’t get off of the couch.”

The 57-year-old wound up losing his job as a delivery driver for FedEx when his limited breathing capacity prevented him from keeping up with the physical demands required for package delivery. Fortunately, his medical treatment at Monongahela Valley Hospital came with a team that was able to step in and help him even after he returned home.

“Monongahela Valley Hospital’s Community Care Network (CCN) brought me out of a place I didn’t want to be,” Spencer said.

CCN was created in 2017 as a way to assist patients following discharge when many find challenges in following their treatment plans. CCN is offered completely free of charge by MVH.

“These challenges are identified as ‘social determinants of health’ such as lack of transportation, inability to afford medications, food insecurity, difficulty affording utilities and inadequate transportation,” said Lynda Nester, executive director of MVH’s Community Care Network.

Over the past four years, CCN has helped a total of 3,422 patients and had an increase in patients over the past year.

MVH saw a need to better coordinate care across the healthcare and social support continuum which includes the hospital, medical staff, post-acute providers and community support organizations.

“A key role of the CCN has been identifying resources and building strategic relationships that help our patients navigate through both their health providers and community support options,” Nester said.

How does it work?

A CCN member meets with a patient while they’re still at MVH to talk about ongoing care needs and concerns. In Spencer’s case, a social worker and care coordinator met with him two to three times a week to help manage his care once he returned home.

“Those women were wonderful,” Spence said. “They helped me to understand my medications and the doctors’ recommendations. In fact, they even helped me with billing questions. They helped set me up on oxygen and get into pulmonary rehab.”

Spencer said they were even able to help him navigate the health insurance maze and get him on disability.

“The CCN is the way care should be handled because once a person comes to Monongahela Valley Hospital for care, they remain our patient, even after discharge,” Nester said. “When they leave our hospital, we transition them to the next step in their care whether it is to their home, a skilled nursing facility, a rehab center or another hospital.”

Members of the CCN team include doctors, nurses, social workers, behaviorists, navigators and health coaches. Those professionals partner with post-acute care, mental health, hospice and palliative care providers as well as elder communities, religious and spiritual organizations and volunteers to ensure a seamless continuity of care. The team can help ensure patients are following treatment plans, taking their medications and getting to follow-up appointments – all of which are key in preventing them ending up back in the hospital.

“The CCN team has telephonic team meetings every morning and at the end of the day to coordinate and prioritize patient care,” Nester said.

Another focus of CCN is to help patients overcome barriers to living a healthy lifestyle including the ability to afford medicine, food, utilities or even safe housing by connecting them with resources that can help.

“We hold weekly calls with home care and skilled nursing facilities to coordinate post-hospital follow-up,” said Sue Flynn, who is a member of CCN’s executive leadership. “In addition, we have very strong relationships with our medical staff and enlist their feedback and clinical guidance when caring for their patients.”

Helping patients flourish is very fulfilling for members of the CCN team.

“One of the most moving memories that I have was a patient who was so excited to show me the features of the winter coat the team had obtained for him,” Nester said. “It is very rewarding seeing people like Greg overcome the barriers to managing their health. The team members are especially proud when they solve a particularly complex problem or provide a resource for a patient.”

Spencer said he is very grateful CCN was there to help him.

“I just don’t want to sit around,” he said. “I have to keep moving and the CCN helped me get back to life.”